Remittance Advice Updates and Deleting Service Lines from Claims

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Remittance Advice (RA) Updates – Incorrect Dollar Amounts Reported for Claims Adjustment Reason Codes (CARC) 23 and 45, TR 27287 

Effective October 17, 2017, MIHMS will be updated to correct dollar amounts associated with CARC 23 and 45, populated on the Remittance Advice (RA) and 835. Currently, the system does not populate correct dollar values associated with these CARCs and is sometimes using CARC 94 or CARC 96 in error. 

  • CARC 23 should reflect the primary insurance carrier’s payment plus any adjustments.
  • CARC 45 should reflect the adjustment/contractual obligation to the provider.
  • CARC 96 should only be used in a denial situation. This CARC will still be used in some situations until we have finished completing the RA/835 updates. You should see a decrease in the number of times CARC 96 is used with this system update.

Example for CARC 23:

Total Charge 50.00
Medicare Payment -30.00
Medicare Contractual Obligation (C/O) -5.00
   
Balance is Coinsurance 15.00

Until the system update, CARC 23 is missing on some secondary claims and other secondary claims will reflect both CARC 23 and 45 amounts under CARC 45. The example above shows that CARC 23 will reflect $35.00 and MaineCare’s responsibility will be $15.00 when the system is updated. 

Example for CARC 45:

Total Charge 50.00
MaineCare Payment -30.00
MaineCare Adjustment -20.00
   
Balance 00.00

Until the system update, some primary claims will reflect a CARC 96 instead of a CARC 45 in error. The example above shows that CARC 45 will reflect $20.00 when the system is updated.


Deleting Service Lines from Claims Previously Submitted via 837 Electronic Data Interchange (EDI) Batch or Paper 

The Health PAS Online Portal Direct Data Entry (DDE) will not allow deletion of service lines on claims entered via EDI 837 batch or paper. If needed, providers can submit an adjustment via EDI, or reverse the claim on the portal DDE and uncheck the box “use the data from this claim as the basis for the new claim” that is found on the reverse claim pop-up page. Claims originally submitted on the portal DDE will allow for the deletion of service lines. Refer to the MHP Claim Submission User Guides for more information or contact the Provider Services Call Center at 1-866-690-5585.